Ask the Experts: Oct. 21, 2009

Q: What would you consider a complete GI exam under the 1995 E&M guidelines?

A: When you refer to a "complete" GI exam, I am assuming you mean a comprehensive exam. There are four levels of examination in the E/M guidelines --Problem focused, Expanded problem focused, Detailed and Comprehensive.

The 1995 E/M guidelines (http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf) define a comprehensive physical exam as "a general multi-system examination or complete examination of a single organ system." Then, the documentation guideline states, "The medical record for a general multi-system examination should include findings about 8 or more of the 12 organ systems."

Unfortunately, this is the extent of the 1995 guidelines for a comprehensive exam. There are no specific guidelines for a complete examination of a single organ system. The 1997 guidelines have got much more specific details about specialty specific exams. The 1997 guidelines are located here http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf

I hope this helps!

Amy Hodges, CPC, CPC-I

Q: A patient presents to the hospital after a fall. Patient is found to have hip fracture and is scheduled for hip repair. On routine pre-op chest X-ray, pneumonia is found and treated with IV antibiotics during the hospitalization. Should hip fracture be the principal dx or could pneumonia be sequenced first? An auditor told us there was no coding rule that says you have to use the diagnosis for which surgery was performed if both conditions were present on admission (POA). Seems the hip fx dx used the most resources and a "procedure unrelated to principal dx" DRG would not be appropriate.

A: The correct principle diagnosis based on the information you supplied would definitely be the hip fracture. The principle procedure would be hip repair procedure code. In this case, you should not have a case of a "procedure unrelated to principal dx."

Now there may be cases where a "procedure unrelated to principal dx" may have to be assigned such as in the case of a patient being admitted for one thing that did not require surgical management, but develops a totally unrelated complication later on that does require surgical intervention. But in all cases, the principle diagnosis must meet UHDDS definitions: "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."

There are rare cases when there are two diagnoses that are both POA and require equivalent treatment and thus may equally meet this definition, and if the pneumonia was POA, this may be one of those cases. In that case, I would still recommend making the hip fracture principle because the most major and definitive treatment was directed to this condition and in this way, you can avoid the "procedure unrelated to principal dx" issue. OIG and other integrity programs are closely scrutinizing cases where the procedure is unrelated to the principal dx.

Christina Benjamin, MA, RHIA, CCS, CCS-P

Q: Inpatient with COPD exacerbation also has steroid-induced hyperglycemia. What ICD 9-CM do you use for the steroid-induced hyperglycemia? This is a Medicare patient in an acute setting.

A: The hyperglycemia was induced by the use of steroids so the code would be 790.29 for the hyperglycemia and code E932.0 for the adverse effect of the steroids. If the documentation supports that the patient was on steroids for a long period of time, I would also add the code V58.65 for the long-term use of steroids. See the Official ICD-9-CM Coding Guidelines, October 2008, Section I, C, 17, e, page 61 for the adverse effect guidelines.

Mary Mills, RHIT, CCS

Q: How do you code a laparoscopic cholecystectomy with attempted intraoperative cholangiogram? Do I use CPT code 47563 with modifier 52 or do I use CPT code 47562?

A: The correct code and modifier depends on what type of claim you are attaching the codes to. For a physician claim, coder would use code 47563 with modifier 53.

In an outpatient hospital or ASC setting, the coder would select code 47562. Please see the information below, which is from CMS regarding correct modifier usage. You can obtain the entire Transmittal via the following link: http://www.cms.hhs.gov/Transmittals/downloads/R442CP.pdf

The use of modifier 52 is now only for radiology procedures (70000 codes) that do not require anesthesia.

Modifiers provide a way for hospitals to report and be paid for expenses incurred in preparing a patient for surgery and scheduling a room for performing the procedure where the service is subsequently discontinued. This instruction is applicable to both outpatient hospital departments and to ambulatory surgical centers

Modifier -74 is used by the facility to indicate that a surgical or diagnostic procedure requiring anesthesia was terminated after the induction of anesthesia or after the procedure was started (e.g., incision made, intubation started, scope inserted) due to extenuating circumstances or circumstances that threatened the well being of the patient.

For purposes of billing for services furnished in the hospital outpatient department, anesthesia is defined to include local, regional block(s), moderate sedation/analgesia ("conscious sedation"), deep sedation/analgesia, and general anesthesia. This modifier code was created so that the costs incurred by the hospital to initiate the procedure (preparation of the patient, procedure room, recovery room) could be recognized for payment even though the procedure was discontinued prior to completion. Prior toJanuary 1, 1999, modifier -53 was used for reporting these discontinued services. Modifiers -52 and -53 are no longer accepted as modifiers for certain diagnostic and surgical procedures under the hospital outpatient prospective payment system. Coinciding with the addition of the modifiers -73 and -74, modifiers -52 and -53 were revised. Modifier -52 is used to indicate partial reduction or discontinuation of radiology procedures and other services that do not require anesthesia. The modifier provides a means for reporting reduced services without disturbing the identification of the basic service. Modifier -53 is used to indicate discontinuation of physician services and is not approved for use for outpatient hospital services.

The elective cancellation of a procedure should not be reported.

Modifiers -73 and -74 are used to indicate discontinued surgical and certain diagnostic procedures only. They are not used to indicate discontinued radiology procedures.

C - Termination Where Multiple Procedures Planned

When one or more of the procedures planned is completed, the completed procedures are reported as usual.

When one or more of the procedures planned is completed, the completed procedures are reported as usual. The other(s) that were planned, and not started, are not reported. When none of the procedures that were planned are completed, and the patient has beenprepared and taken to the procedure room, the first procedure that was planned, but notcompleted is reported with modifier -73. If the first procedure has been started (scopeinserted, intubation started, incision made, etc.) and/or the patient has receivedanesthesia, modifier -74 is used. The other procedures are not reported.

If the first procedure is terminated prior to the induction of anesthesia and before the patient is wheeled into the procedure room, the procedure should not be reported. The patient has to be taken to the room where the procedure is to be performed in order to report modifier -73 or -74.

Lisa L. Withers, RHIT, CCS

The consultants, their companies and ADVANCE do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information.

Coding Clinic is published quarterly by the American Hospital Association
CPT is a registered trademark of the American Medical Association.

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